trans*scribe illustration ©rosa middleton, 2013
On March 22nd, I paid a dude to knock me unconscious, peel back my face, and cut out big chunks of my skull and jaw. He was surrounded by nurses, which is always a good sign, and I have his solemn word that he went to grad school. But that’s what happened. That’s what I spent the better part of five months making sure would happen. It’s a surgery that I think of as the final component of my transition, a struggle to claim and assert a female gender identity spanning many years.
“Facial feminization surgery” (FFS) is a subspecialty of transgender medicine drawing from cosmetic and reconstructive oral, dental, maxillofacial and otolaryngological (ENT) surgical fields. FFS describes any procedure(s) performed on the head and/or neck in order to increase the likelihood that their owner will be “recognized as female” by observers, including and especially herself. You can remove bone bossing and cartilage outgrowths caused by sustained exposure to testosterone and augment soft tissue features, such as facial fat, which have not responded adequately to HRT. Some of the techniques used for FFS are subtle and borrowed from routine cosmetic medicine, like facial fat grafting and rhinoplasty. Others, such as brow reconstruction, are more aggressive and incorporate the most sophisticated tricks in the modern surgical playbook. FFS isn’t really about getting a new face – it’s about getting the face you would have been able to take for granted without that unfortunate first go at puberty.
While FFS tends to be “beautifying” and can make it easier to walk among the mean girls, morons, and psychopaths who litter the Earth, these are fringe benefits. People get FFS to treat gender dysphoria, a pervasive, limiting and even life-threatening form of discomfort experienced by transgender people.
This model isn’t perfect, and doesn’t fit everyone’s experience, but it’s helped me understand a lot about myself, and speaks to why I pursued FFS. As a child and young adult, I’d stare at my face in the mirror every chance I had and have no idea what I was looking for. These things would happen, I’d realize that they were at least a bit unusual, and I was left to figure out what the hell it said about me. It wasn’t fun, and I kept it to myself.
A few months after college graduation, I had one of your textbook near-death experiences and decided to grow up. Learning about FFS was one of a few things that helped get me started. I’d begun reading about gender reassignment, and saw a few of the classic examples of aggressive facial reconstruction. I had never really dared to ask myself if I would want something like this, it had seemed out of reach in some obvious, fundamental way. Allowing myself to think otherwise was like flipping a switch. I was still terrified and thought that I was almost certainly going to die, but it was impossible to take back. It was what I needed to do. So I did it.
I “went full-time” eight months ago, almost two years after deciding to transition. It was better for me than I’d ever dared hope, and fixed problems I didn’t even know I’d had. I actually knew what good mental health felt like. On the very same week that I’d made it all legal, I landed a new job. Not only did this let me escape my second layoff in two years, I began working immediately with new people. These weren’t just good coworkers, they were people who hadn’t known me as a guy, or worse, as a ticking time bomb of sensitivity training. I was given my first managerial position and charged with coordinating a small army of volunteers. I became a published author. I was settling into a life that felt like my own, and my voice and confidence improved rapidly.
Many of the compulsions, neuroses, and anxious or painful feelings I’d come to associate with my gender dysphoria had faded out of even the background of my life. My face had improved, but it remained a source of anxiety and distraction, even on good days. HRT had helped a lot, but it has limits. There isn’t a pill made that can change bone structure like that. Every single day, I had moments where my face would make me feel insecure. I’d overcompensate in ways that left me feeling embarrassed and depressed, and often found myself distracted from people I cared about.
In some ways, it had gotten worse: I hadn’t liked being a guy, but the world accepted it and my face fit into that. That obviously didn’t help anymore. I had a year until I would be learning medicine, in a new city, with new people – I wanted to give it everything I had. I didn’t want to spend every morning in Chicago fighting my reflection to get out the door. If there were ever a good time to get major surgery, this would be it.
My doctors were supportive, but they could only tell me so much. There were one or two names half-remembered, promises to “look into it” for me. That chicken came home to roost months later, as a jarring email from the head of the local plastic surgery department. Dr. B wrote to reference one famous guy – the father of the FFS field, more or less – and declared that while he’s “never done much of this, really,” he would “probably be the next best option” if the Big Name were unavailable. Well shit, doc, that sounds like a plan! Why don’t you just come over, hit me with a 2×4 and we’ll get to cuttin’.
I collected names from web directories and journal articles, and cross-referenced them exhaustively with 7-10 of my friends who’d had FFS procedures ranging from minimal to highly aggressive. (I’d helped moderate a small online forum, and had stayed in touch with trans people all over the world.) I drove downtown during lunch one day, rubbed off my makeup, peeled back my hair, and had a photographer document my features at their most exposed: hairline, brow, thyroid cartilage, chin, and jaw.
My pictures went out with a short letter, walking through who I saw myself as and how I felt about my face as best as I possibly could. I made sure to stay positive – I liked my severity, my cheekbones, my close resemblance to my mother and younger siblings. I tried to explain what worked and what didn’t. “Passing better” would be nice, but I knew damn well that I was beautiful – the problem was that my focus and confidence were at the mercy of lighting, cosmetics, and a charitable mood. Reading these old letters, I’m struck by how much I had to worry about. I wanted to do this once and to have that be enough, forever. I had that unthinking fear of “excessive plastic surgery” like the paparazzi were just around the corner. I didn’t want to lose myself, I didn’t want to be a fucking Barbie doll. A couple of very high-pressure paragraphs, but it turned out alright. My friends insisted, “these guys are used to way worse.”
My friend Eliza Gauger signed on for mock-ups and aesthetic support. Eliza and I had met through unconventional public health outreach work, but she’s also a killer artist, model, dancer, and the last person you want to cross in the dead of night. We both understood FFS as a science developed to produce conventional, Western, cis-passing beauty. That isn’t necessarily bad for me, but it’s bad for plenty of other people and recognizing the implicit bias in the field is kind of disturbing. It seemed important to understand what these changes meant to me, and to other people, and why. Some of same cultural filters applied in other STEM topics are found here. It’s all good when you’re asking what to cut and how to stitch it back up. It’s less convincing to say that you can atomize the face and collect statistics on modifications of its components and come up with reliable aesthetics. I think it would be a fine thing if plastic surgeons were to pay artists lots of money to interrupt them during consultations, don’t you?
I worked through my list. One of the famous names had seemed like a good option, even if his approach – “I’ll list every single procedure I can think of that would help feminize you, just pick the ones you want” – made my skin crawl. I asked one question too many about a technique he’d developed and recommended to me, one too many about insurance, and his people stopped talking to me. It was as simple as that. Another charmer gave me two sentences: “My colleague, Dr. Q, can do the surgery. He recommends jaw and chin reduction.” Another surgeon seemed to catch on that I was just a bit neurotic. I’d approached him with a plan cobbled together from previous consultations and he started to pick out trivial aspects as “risky” or “unusual.” Fortunately, these were things that I knew were bog standard in the FFS subspecialty, like combining a brow reduction and hairline repair. It’s the same fucking incision! A similar drama played out over chin and lip procedures. He used every chance he had to suggest that other surgeons would turn me into a circus freak. I’m convinced that he was trying to scare me into working with him. It was horrifying.
I wrote Dr. T while he was performing charity surgeries in Eastern Europe, and we began corresponding extensively by email. He was finishing his training before inheriting a well-known practice in my area. We got along well: Dr. T was the first and only surgeon I’d contacted who would directly connect his advice to the goals I’d expressed. I’m not sure that anyone else had even talked about family resemblance, not even to tell me if I was worrying about nothing. He was also the most willing and able to have a full technical and aesthetic discussion about his recommendations. It was some of the Bill Nye experience I’ve chased in my academic and professional life.
Dr. T had started with the “rule of thirds.” When a face is divided into vertical thirds of relatively equal height at the lower brow and just under the nose, it tends to be read as more feminine. Women in my family have powerful chins, but androgen exposure had pushed things a bit far in my case. A reduction in that area was one tool for restoring proportionality. Something about the lower half of my face had bothered me, but it had been hard to figure it out. This idea sat well with me. Jaw reduction is a more aggressive approach, with a longer recovery.
Other recommendations were extremely conservative, but clever – Dr. T mentioned that fat grafting tricks that might help with my brow, among other areas. While it’s true that fat grafts are less invasive and can look great, they’re difficult to make permanent. Whatever I did needed to stick, and my brow bothered me.
For the brow, you have two basic options: reconstruction and reduction. A simple brow reduction is limited, because you cannot expose the patient’s frontal sinus. The size of this cavity varies dramatically, and it is sometimes even absent, just like the bossing that covers it. But it needs to stay intact, and that’s made aggressive brow reconstruction the shining jewel of FFS techniques. There are multiple variations, including several that call for removing the entire bone and grinding it down on a table before grafting it back. With rare exceptions, these are techniques that are universally recognized as sophisticated, safe, and effective.
This is where I’d been discouraged. I had assumed my options were generally safe, and had seen the degree of change that was possible years ago. I wouldn’t mind something radical per se, but I wanted to talk about it. Unfortunately, while the Great Men behind these techniques do genuinely beautiful, sophisticated work, they all seem to think that theirs is the only sane and effective approach for reduction. When I consulted with one such surgeon, he hardly seemed to care about matching the brow to the patient, even in the context of his preferred technique.
Dr. T’s response indicated that he felt competent with at least one of the aggressive reconstruction techniques, but he’d reached similar conclusions. It does make people look very different. It was up to me, but from how I’d described myself, that didn’t seem like what I was looking for. And no, really, it wasn’t. Eliza had made a mock-up of combined chin and simple brow reduction that was kind of astonishing to look at, and Dr. T was willing to sign off on its accuracy. That would do it.
A reduction genioplasty (chin shave) via osteotomy and simple brow reduction/brow lift would be the major components of my operation. I also insisted on a lateral hairline advancement. While Eliza and Dr. T had correctly noted that my central hairline was well-positioned and the sides were almost totally unnoticeable, it was exactly the kind of thing that drove me crazy. Every gust of wind, hairpin, itchy spot, tie, or hat disturbed the thick horns of scalp running up both sides in a classic “M” shape. I had to style my hair differently to compensate, and rearrange it carefully when I tied it behind my head. It just fucking sucked, and like I said – same incision.
I’d waffled on reducing my thyroid cartilage. The “Adam’s apple” is such a stereotypical focus when people talk about trans women’s bodies. Mine really wasn’t prominent, but I wouldn’t miss it either. I hated the idea of getting cut more and risking my hard-earned voice just for other peoples’ benefit. I slowly came to feel that it was something I looked at, and did bother me a little, and it might hurt to have that be the last thing that got to me in this way. It went on the list.
So basically, I was ready to go. Then other people happened.
It was as though the world was determined to keep me from getting what I needed. Work exploded. I had an emergency wisdom tooth extraction. A surgery scheduling error set me back three weeks. I needed to borrow money from a tuition fund that my grandfather had left me in Waco, and we’d decided that what the simple folk of Merrill Lynch didn’t know about me wouldn’t hurt them. I assumed my former identity for the first time in half a year, acting as my own receptionist and hiding in the lab’s darkroom to take their calls. Like a lot of my life, it’s funny now because it worked and everything’s fine. To cut my risk of bleeding and clotting problems, I stopped taking estrogen, a skin-crawling first in sixteen months. I told my father – hey, going to get some stuff done at this place and time, it’s all fine, but I’d love a visit.
My father was an unhappy, emotionally abusive man throughout my childhood, but children can normalize just about anything and I blamed myself for feeling uncomfortable and afraid around him. When I started to come out, I felt obligated to help him understand me. It wasn’t the best plan. My transition was an unacceptable departure from his script, a sign that I must have some “underlying” problem that would be intelligible to him. I just needed to take his money and go backpacking in Sweden, or do some other horrible privileged white shit. As a boy! Had I really considered how a tall, big-headed, big-boned emm-tee-eff would get along with the straight world?
When I told him about the surgery, it was clear that nothing had changed. First came the good old referendum on my personality. This time, he fixated on my qualified distaste for Andrew Solomon’s appearance on Katie. H-how could I? That guy’s book was great! Then it was time for Dad to Help Out with, not even joking, top google results for “facial feminization surgery.” Have you ever seen bad plastic surgery? It’s gross! I had interrupted his secret honeymoon in Bali to tell him that I was getting major surgery, and this was very selfish, very thoughtless indeed. And so near my little brother’s birthday, how could I? My insistent, fulminating transsexualism only proved the depths of my bitterness, my narrow-minded self-loathing.
Telling my father that he’s an abusive, neglectful parent – that I have to see him as a problem to manage, in an ironic reversal of our relationship over all those years – was the one thing I’d held back. It was the easiest thing I’d done all day. That was the last thing I’d let myself think might get through to him, and the last unfinished business between us. He said that it was “very sad” that I felt this way, and that he sure hoped it gave me strength. He wrote again, hours later, to say that I was making it all up. My “uncontrolled anger” could only mean that I’m in “deep trouble.”
Maybe he’ll be hit by lightning and wake up a better person. I’m not holding my breath. Right now, it’s enough to have that person out of my life.
I felt like an enemy of the Old Testament God as my plague of WASPs continued. My mother had made friends with an older trans woman through her work, Helen. Helen was a wealthy woman who’d transitioned later in life. She’d been a little more interested in me than I was totally comfortable with, but I know what it’s like to want to be there for people. We’d gotten on well the first time we’d met in person, and I hoped she’d be a good friend to talk to during an increasingly nutso part of my life.
We met for drinks nine days before the surgery. I brought this up and mentioned how bullshit everything had become, and regretted it very quickly. Helen was on me like flies on shit. She had decided against getting FFS, and naturally that made it “the riskiest” trans-related surgery, it was “the last thing you do.” Had I worked with her guy? Why hadn’t I worked with her guy?
I was stunned. I was talking to someone who’d had breast augmentation and SRS. The risks of each are considerable, they happen to scare the hell outta me, and neither is something I want for myself if I can help it. But who fucking asked me? It’s none of my business. So what the fuck?
I did my best to be kind, and I think it was a mistake. You’re not going to change my mind, I said, and I’ve just disowned my father, this isn’t the sort of conversation I can have right now. But holy hell. The woman had fucking pulled rank on me, babbling about “the view from fifty thousand feet up.” I guess Lasik is better than I’d heard, if you can even fuckin’ see me from there. She started up again via text message at seven thirty the next day. I’m not sure what she was expecting, but she didn’t like the result. Good.
It was wearing me down. My mom and stepdad are kind, smart people, and they’re my heroes, but their anxiety reached a fever pitch. I found myself being asked – What about the laryngyscope? What about the bone paste? These weren’t bad questions. A lot of them were really good ones. But it felt like far too late for me to worry about that shit. We reached a low point when I found out that they’d quietly gotten in touch with the Big Name who’d dumped me. I was expected to fly out to see him, “just in case.” I was angry. I didn’t have a lot to actually worry about, but I didn’t want to see them that freaked out when it couldn’t change my decision.
My parents’ distress was impossible to completely ignore. It’s like when toddlers take a fall and look to see how adults react before crying or not. I had been ready, and still was, but between this and everything else I was feeling a lot less lucky. Insurance was no longer a sure thing and I wanted to be able to support myself and my partner through our move if that and her job hunt came to the worst, so it was prudent to cut costs. Thyroid cartilage fell off the list.
I’m not sure what to say about that. It was never that big of a deal. I’m sure that I can find a way to do it if I really need to. I was phenomenally, singularly lucky to be able to make even these decisions for myself. Most people don’t have access to even basic medical care in this wasteland. I was only looking for some of what others take for granted, but I still knew that I was getting a lot.
On Friday the 22nd, I fasted from midnight, tossed and turned until dawn, and rode with my family to a surgical center in San Rafael. I handed over a cashier’s check and my advance directive. I changed into robes, met my nurses and anesthesiologist, and got stuck with an IV. The mood was difficult, but better than I’d feared. We’re strong people, and just as importantly, it was six thirty in the God damn morning.
I was conscious in the operating theatre for maybe fifteen seconds. I hopped onto the table, extended my arms as directed, and thanked the nurse at my left shoulder for going ahead with the obvious crucifixion joke. Before I could wonder if she said that every time and if it had started to bother people, I was drugged unconscious and summarily catheterized.
A small incision was made under my chin, through the soft tissue envelope that lines the skull. Retractors positioned the surgical window over the anterior of my jaw, below my lower lip. An osteotomy was created, defining a wedge of bone. This was removed, and the new bottom and top halves of my chin were joined together with titanium. At our pre-op appointment, I’d asked Dr. T if I could keep the osteotomy “to make earrings and impress my Goth friends,” and he’d offered to give it a shot. I’m told that the on-site pathologist balked, and they run the show. This was too bad – as you can guess, I am my Goth friend.
An incision was made along my hairline to the bone, and bleeding was stopped via electrocautery. The entire upper third of my face was peeled down, stopping at the eyelids. A bone burr was used to progressively remove portions of my frontal brow and orbital rim bossing, terminating at the earliest transition from white- to off-white bone tissue that marked the safe limit for this procedure.
My face was returned to its original position, then stretched subtly to effect a brow lift at the upper outside edges. Excisions were made at the hairline to compensate for the lift, and then at the lateral edges. This repaired and reshaped the bald strips that had given it such a recognizable “M” shape.
After a 6.5 hour operation, I came to in the same room where I’d gotten the IV. My view was squeezed in, obscured on all sides by ACE bandages and a head cast. A drain and collection vessel hung from the cast, its point of origin a length of surgical tubing that extended from under one corner of the hairline incision, along at least six inches of scalp. There was the predictable soreness everywhere that had had a tube shoved in it, and my jaw and forehead felt like God had wiped His ass with them. They also felt different. I could touch them, gently, and be sure. Holy shit. Whatever had been done to my brow was more than I’d let myself expect, but still totally familiar. Okay. I was at my parents’ house by four in the afternoon, and back home the next day.
Recovery has been fantastic. I’m still fighting my insurer as they try to defraud me. But the time leading up to surgery was hell and I’m bouncing back faster than I’d ever expected. The pain is non-negligible but well managed. Sometimes, I can feel tiny spaces between the soft tissue and bone where things are still snapping back together. It’s awesome. I have nerve damage that numbs my scalp and parts of my lower front teeth, with small patches waking up periodically to remind me that they’re pissed off. It’ll probably heal completely in time, driving me bonkers every step of the way. I’m not even slightly worried.
There’s so much ignorance about how people like me relate to surgery – first off there’s this obsession with SRS, “the” surgery, the “sex change” surgery, blah blah blah. And people tend to project that obsession onto us. Most people don’t understand what it means to want life-altering surgery. Most people are fortunate enough not to have to. Few are in a position to make it happen on their own.
I’m less sure about my other concerns. I feel flipping great about my choice of surgeon. People develop very personal relationships with providers over this, and it is a very personal situation, and maybe that’s fine. It’s hard not to see an element of Stockholm Syndrome in the obsession with the few famous surgeons, especially after my run-in with Helen.
I haven’t talked much about the results yet because I want to say this as clearly as possible, and because I want to end on a good note. So here it goes: the surgery fixed me. For all the noise, the fear, the second-guessing, and the waiting, it was as simple as that. I don’t need to hold my breath until I’m fully healed, although I’m sure there’s more to look forward to. I was better the second I woke up. Parts of me have a different weight. I protrude into the world differently than I did before, and it’s fucking cool. I can feel it when I talk, smile, and laugh.
I’ve been very diligent about recording my transition. Our doctors may no longer advise us to tell our children that we’re dead and move to the other side of the country, but the world still says that transition is incompatible with normal life. It’s something you keep a secret. Being public was a way of showing that I wasn’t afraid, even if I was kind of obviously vulnerable.
It was also a way to preserve evidence. When I was in a particularly bad mood, I could remind myself that I often looked or sounded just fine, and probably even did at the moment. It helped solidify the idea that dysphoria is a pathology. It wasn’t a part of me that I needed to trust or accept, and it wasn’t other people saw. It was something to ignore and wait out until I was myself again. You can probably imagine how I felt about recovering from major surgery, smartphone in hand. Maybe I could shoot a time-lapse!
I’ve done some of that, but it’s felt a lot more like work than it used to. I think that I’ve spent less time looking in the mirror this week than at any other point in my adult life. I’m not avoiding it. God knows my eyebrows have needed attention after a few days in a head cast. But I just see myself and don’t have to fucking look for it any more. I feel secure about my identity in a way I’ve never been able to before.
Getting FFS has been what lets me take it for granted. The idea that I’m female can become something unremarkable and basic about me, even if just in my own head. I understand if that doesn’t make sense: I’m very tall, I spend more time than most on hair management and have hands that would make Lana Kane blush. My breasts are “totally excellent” but may or may not ever quite match my ribcage. And, oh right, I can pee standing up. But call the cops, I don’t give a fuck. I’m grateful.
Olivia is a scientist, cooking enthusiast, and latent telepath currently evading the authorities in San Francisco, CA. She likes sour patch kids and carries a waiver of discretionary termination in seven systems.
Special Note: Autostraddle’s “First Person” personal essays do not necessarily reflect the ideals of Autostraddle or its editors, nor do any First Person writers intend to speak on behalf of anyone other than themselves. First Person writers are simply speaking honestly from their own hearts.